Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 34 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
25D
2E
4F
Potential for minimal harm
0A
0B
0C
June 24, 2025Complaint inspection · 1 citation
- G
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure safe and comfortable temperatures were maintained in residents' bedrooms by failing to repair one of eight rooftop air-conditioning (A/C) units resulting in temperature readings between 89.8- and 90.0-degrees Fahrenheit (F) on 06/23/2025, for one resident (#5) of twenty sampled residents. These failures resulted in physical discomfort for a dependent resident and the likelihood of significant harm due to unsafe temperatures exceeding 81-degrees Fahrenheit.
April 30, 2025Complaint inspection · 7 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wrote2. On 4/29/25 at 9:17 a.m., Resident #7 was observed lying in bed. The resident's bottom teeth were covered with a yellow/tan colored substance and a watery, tan colored liquid was observed in the resident's mouth. An intravenous (IV) pole was standing between the bed and window and hanging from the pole was an empty IV medication bag, labeled with the residents name, name of the medication Zerbaxa, and tubing wrapped around the wings of the pole. The IV medication was dated 4/28/25 and not running. Review of Resident #7s medical record showed a medication list from an acute care facility, printed on 4/17/25 at 10:46 a.m., revealing the resident was to receive ceftolozane-tazobactam 1.5-gram (g) in sodium chloride 0.9%, 100 milliliter (mL) IV piggyback (IVPB) - Infuse 1.5g into a venous catheter every 8 (eight) hours for 35 doses. Last time this was given: April 17, 2025, at 6:05 a.m. [...]
- F
Post nurse staffing information every day.
Inspectors wroteBased on observations and interviews, the facility did not ensure the posted nurse staffing data was up-to-date and current from 4/18/25 to 4/30/25.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to thoroughly investigate and provide staff with education following a medication error incident for one resident (#4) of one resident incident involving medication errors.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure oxygen therapy was provided as ordered for one resident (#6) out of three residents reviewed with continuous oxygen.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide staff with the appropriate competencies and skill sets to assure three residents (#4, #7, and #9) received medications as ordered by the physician.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interviews, the facility did not ensure routine physician-ordered medications were acquired and provided upon admission for two residents (#3 and #8) of two residents reviewed.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a medication administration error rate of less than 5.00%. Twelve medication administration opportunities were observed, and three errors were identified for one resident (#9) of one residents observed. These errors constituted a 25% medication error rate.
June 24, 2024Standard inspection · 10 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on interview, record review and observation, the facility failed to ensure the reach-in cooler was maintained in a sanitary manner in one of one kitchen.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interview and record review, the facility failed to ensure the facility had an Infection Control Preventionist (ICP), who had specialized training in Infection Control and Prevention.
- F
Keep all essential equipment working safely.
Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure essential kitchen equipment was maintained in a safe operating condition in one of one kitchen.
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of admission diagnoses on the Level I Preadmission Screening and Resident Review (PASRR) and failed to update the Level I PASRR upon the addition of new diagnoses for thirteen (#43, #40, #6, #59, #37, #11, #12, #14, #64, #29, #42, #38 and #36) of sixteen residents reviewed for PASRR.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review, the facility failed to ensure timely completion of the Minimum Data Set (MDS) assessment for four (#47, #273, #57, and #17) of thirty-two sampled residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one (#1) of thirty-two sampled residents.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review, the facility failed to complete the baseline care plan in a timely manner for one (#274) of thirty-two sampled residents.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the comprehensive care plan for four (#55, #11, #12, and #14) of 32 residents reviewed.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide oxygen therapy in accordance with professional standards for four (#14, #274, #47 and #29) of four residents sampled for oxygen therapy.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview, observation and record review, the facility failed to ensure physician ordered psychotropic medications used on an as needed basis were limited to 14 days use for one (#273) of five residents sampled for unnecessary medication use, and failed to ensure behavior and side effect monitoring of psychotropic medication use was completed in accordance with physician orders for four (#11, #14, #24, and #64) of eight residents sampled for medication monitoring.
August 11, 2022Standard inspection · 11 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review the facility did not ensure pain management was provided consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one resident (#35) out of three residents sampled for pain.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and policy review facility failed to maintain dignity while dining for one resident (#222) out of twelve residents sampled for dining
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage and the Center for Medicare and Medicaid Services form 10123-NOMNC was completed and provided to one (#273) out of three residents reviewed whose skilled services ended.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide written notification of Transfer to Resident representative for one (Resident #26) of two sampled residents.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide written notification of Bed Hold Policy to the resident representative for one (Resident #26) of two sampled residents.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure appropriate restorative services were provided for one ( #55) out of two sampled residents with limited mobility and maintain independence with splint application. Findings Included: On 08/08/22 at 2:05 p.m. Resident #55 was receptive to an interview and said he had been at the facility longer than he wanted to be. He indicated he needed assistance with his care and services. His left hand was observed resting on top of his lap and presented with a clenched fist. Resident #65 confirmed his fingers were clenched and stated, it happened after my Cerebral Vascular Accident (CVA). The resident was able to move his left-hand fingers off the palm of his hand slightly with the assist of his right hand. When he removed his right-hand away from his left hand his fingers returned to a clenched state. [...]
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure daily monitoring of resident behaviors was conducted in order to ensure the appropriateness and continuation of the psychotropic medication regime for two residents (#56 and #57) of five sampled residents for unnecessary medications. Finding Included: On 08/09/22 at 12:52 p.m. Resident #56 was in his bedroom watching the television. He looked up when approached and appeared comfortable. He shrugged his shoulders in the I don't know gesture when asked how long he had resided at the facility. He then turned back in the direction of the television. On 08/10/22 at 12:19 p.m. Resident #56's nurse said the resident had a scheduled outside appointment today and had declined to attend. She said he needs to go to his dialysis appointment. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and medical record review the facility did not ensure the medication error rate was below 5 % for two (# 56 & 174) of 5 sampled residents who were administered medications. This resulted in 2 errors from 28 medication administration opportunities for a medication error rate of 7.14%. Findings Included: 1. On 08/09/22 at 5:19 p.m. medication administration observation task was conducted alongside Staff Member K, a Licensed Practical Nurse as he performed a blood glucose test on Resident #56. The blood sugar level reflected a reading of 184. Staff K returned to the medication cart and removed a Novolog Flex Pen 100 unit/ml solution pen -injector. He dosage selector was set to 2 units. When asked what the resident blood sugar level was, he looked back at the computer screen and stated oh, it's supposed to be 4 units. He then dialed the pen to four units. [...]
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview and policy review the facility failed to maintain proper storage of medication for one resident (#30) out of 39 sampled residents, in two out of four medication carts, and one out of two medication storage rooms.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and the Health Insurance Portability and Accountability Act (HIPAA) of 1996 the facility 1) failed to maintain protected health information (PHI) for two residents (#56 and 174), and 2) failed to maintain the security of a computer screen with PHI information displayed for multiple residents out of 75 residents sampled during the survey. Findings Included: On 08/09/2002 at 5:30 p.m. medication administration observation task was conducted alongside Staff K, Licensed Practical Nurse. Staff K removed a white plastic pouch from the medication cart. The pouch indicated it was for Resident #56 and resident name, room number, unit number the facility name, the Physician name, medication names that were due at that time, and the prescription (RX) number were all listed on the pouch. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and policy review the facility 1) failed to maintain proper infection control standards to provide a safe, sanitary environment regarding COVID-19 precautions for three residents (#5 , #175, and #222) on two days (8/8 and 8/9/22) out of four days surveyed , 2) failed to maintain infection control policies related to staff's personal items in resident care areas on two days (8/8 and 8/10/22) of four days surveyed, and 3) failed to maintain sanitary conditions for the facility ice machine on two days (8/8 and 8/10/22) of four days surveyed.
March 26, 2021Standard inspection · 5 citations
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three Residents (#44, #376 & #378) were receiving oxygen according to professional standards of 3 residents observed. Findings Included: 1. Observation of Resident #44 on 3/24/21 at 10:36 a.m. was observed wearing oxygen at 2.5 liters via nasal cannula. Observation on 3/24/21 at 2:40 p.m. revealed Resident #44 wearing oxygen via nasal cannula. Observation on 3/25/21 at 8:41 a.m. revealed Resident #44 wearing oxygen via nasal cannula at 2.5 liters. An interview with Staff member H, (Registered Nurse) RN on 3/25/21 at 12:45 p.m. confirmed Resident #44 did not have an order for oxygen. Staff member H stated the resident used to be on 2 liters of oxygen and stated she would add the orders. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one Resident #376 was assessed accurately to represent the wounds and bruises the resident sustained prior to admission of three residents sampled. Findings Included: Observation of Resident #376 on 3/23/21 at 9:45 a.m. revealed the resident with a dark spot and steri strips on the right eyebrow. Observation of Resident #376 on 3/24/21 at 10:26 a.m. revealed the resident with a dark spot on the right eyebrow. During an interview with Resident #376's spouse at the facility for a window visit on 3/25/21 at 11:41 a.m. she stated the resident had steri strips on his eye brow, marks on his knees and other bruises related to a fall at home. Review of physician orders revealed to monitor bruise to left arm every shift dated 3/24/21. [...]
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interviews and medical record reviews, the facility failed to ensure care plan interventions were followed related to falls (Resident #59) and food preferences (Resident #55) for two (2) out of thirty-seven (37) residents sampled.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observations, staff and resident interviews, and record review, the facility failed to honor resident food item preferences during meal services for one of thirty-one sampled residents, (#55), and during two of four days observed (3/24/2021, and 3/25/2021). It was found that resident #55 received multiple food items that were on his dislike list.
- D
Provide and implement an infection prevention and control program.
Inspectors wrote2. On 3/25/2021 at 7:02 a.m. a Certified Nursing Assistant (CNA), Employee N was observed in the 100 new admissions unit. All rooms on the 100 new admissions unit were on droplet precautions with directions to wear full PPE when going inside; PPE signage included wearing of N95 or regular surgical masks. Employee N was wearing a black colored fabric mask with a white plastic corrugated tube leading from mask and attached to a device strapped on her arm. Employee N was assisting nursing staff with a resident emergency so she could not be interviewed at the time of the observation. On 3/25/2021 at 7:30 a.m. an interview was conducted with the DON, and Employee N, Employee N stated she had a medical condition that required wearing a breathing filter apparatus, ordered by her physician. [...]
Fire safety inspections
15 fire safety citations on file: 5 on June 24, 2024, 1 on February 6, 2024, 3 on August 11, 2022, 6 on March 26, 2021.
Every fire safety citation15 citations
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 24, 2024 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 24, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 24, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · June 24, 2024 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 24, 2024 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 6, 2024 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · August 11, 2022 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 11, 2022 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · August 11, 2022 · Corrected (the home has a date of correction)
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · March 26, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 26, 2021 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 26, 2021 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 26, 2021 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 26, 2021 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 26, 2021 · Corrected (the home has a date of correction)